|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$390.10
|
|
|
Service Code
|
NDC 904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$292.57 |
| Max. Negotiated Rate |
$390.10 |
| Rate for Payer: Aetna Commercial |
$351.09
|
| Rate for Payer: ASR ASR |
$378.40
|
| Rate for Payer: BCBS Trust/PPO |
$320.35
|
| Rate for Payer: BCN Commercial |
$320.35
|
| Rate for Payer: Cash Price |
$312.08
|
| Rate for Payer: Cofinity Commercial |
$366.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.08
|
| Rate for Payer: Healthscope Commercial |
$378.40
|
| Rate for Payer: Healthscope Whirlpool |
$390.10
|
| Rate for Payer: Mclaren Commercial |
$351.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.58
|
| Rate for Payer: Nomi Health Commercial |
$319.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$343.29
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$5.48
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.20
|
| Rate for Payer: BCN Commercial |
$12.20
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.36
|
| Rate for Payer: Healthscope Whirlpool |
$14.80
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.10 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.15
|
| Rate for Payer: BCN Commercial |
$12.15
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.36
|
| Rate for Payer: Healthscope Whirlpool |
$14.80
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.78 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$176.13
|
| Rate for Payer: ASR ASR |
$189.83
|
| Rate for Payer: BCBS Trust/PPO |
$160.71
|
| Rate for Payer: BCN Commercial |
$160.71
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$183.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$189.83
|
| Rate for Payer: Healthscope Whirlpool |
$195.70
|
| Rate for Payer: Mclaren Commercial |
$176.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Nomi Health Commercial |
$160.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.22
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$195.70
|
|
|
Service Code
|
NDC 904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.41 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$176.13
|
| Rate for Payer: Aetna Medicare |
$72.41
|
| Rate for Payer: ASR ASR |
$189.83
|
| Rate for Payer: BCBS Complete |
$78.28
|
| Rate for Payer: BCBS Trust/PPO |
$161.35
|
| Rate for Payer: BCN Commercial |
$161.35
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$183.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$189.83
|
| Rate for Payer: Healthscope Whirlpool |
$195.70
|
| Rate for Payer: Mclaren Commercial |
$176.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Nomi Health Commercial |
$160.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$171.47
|
| Rate for Payer: Priority Health Narrow Network |
$137.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.22
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$7.60
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$6.84
|
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Commercial |
$20.16
|
| Rate for Payer: Aetna Commercial |
$16.56
|
| Rate for Payer: Aetna Medicare |
$6.81
|
| Rate for Payer: Aetna Medicare |
$2.81
|
| Rate for Payer: Aetna Medicare |
$8.29
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$21.73
|
| Rate for Payer: ASR ASR |
$19.40
|
| Rate for Payer: ASR ASR |
$17.85
|
| Rate for Payer: ASR ASR |
$7.37
|
| Rate for Payer: BCBS Complete |
$8.96
|
| Rate for Payer: BCBS Complete |
$7.36
|
| Rate for Payer: BCBS Complete |
$3.04
|
| Rate for Payer: BCBS Complete |
$8.00
|
| Rate for Payer: BCBS Trust/PPO |
$16.49
|
| Rate for Payer: BCBS Trust/PPO |
$6.27
|
| Rate for Payer: BCBS Trust/PPO |
$18.47
|
| Rate for Payer: BCBS Trust/PPO |
$15.17
|
| Rate for Payer: BCN Commercial |
$6.27
|
| Rate for Payer: BCN Commercial |
$18.47
|
| Rate for Payer: BCN Commercial |
$15.17
|
| Rate for Payer: BCN Commercial |
$16.49
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Cash Price |
$17.92
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$17.92
|
| Rate for Payer: Cofinity Commercial |
$7.14
|
| Rate for Payer: Cofinity Commercial |
$17.30
|
| Rate for Payer: Cofinity Commercial |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$18.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.92
|
| Rate for Payer: Healthscope Commercial |
$7.37
|
| Rate for Payer: Healthscope Commercial |
$17.85
|
| Rate for Payer: Healthscope Commercial |
$19.40
|
| Rate for Payer: Healthscope Commercial |
$21.73
|
| Rate for Payer: Healthscope Whirlpool |
$18.40
|
| Rate for Payer: Healthscope Whirlpool |
$22.40
|
| Rate for Payer: Healthscope Whirlpool |
$7.60
|
| Rate for Payer: Healthscope Whirlpool |
$20.00
|
| Rate for Payer: Mclaren Commercial |
$20.16
|
| Rate for Payer: Mclaren Commercial |
$18.00
|
| Rate for Payer: Mclaren Commercial |
$16.56
|
| Rate for Payer: Mclaren Commercial |
$6.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.46
|
| Rate for Payer: Nomi Health Commercial |
$15.09
|
| Rate for Payer: Nomi Health Commercial |
$18.37
|
| Rate for Payer: Nomi Health Commercial |
$6.23
|
| Rate for Payer: Nomi Health Commercial |
$16.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.80
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.60
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$22.40
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna Commercial |
$20.16
|
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Commercial |
$6.84
|
| Rate for Payer: Aetna Commercial |
$16.56
|
| Rate for Payer: ASR ASR |
$7.37
|
| Rate for Payer: ASR ASR |
$21.73
|
| Rate for Payer: ASR ASR |
$19.40
|
| Rate for Payer: ASR ASR |
$17.85
|
| Rate for Payer: BCBS Trust/PPO |
$18.39
|
| Rate for Payer: BCBS Trust/PPO |
$15.11
|
| Rate for Payer: BCBS Trust/PPO |
$16.42
|
| Rate for Payer: BCBS Trust/PPO |
$6.24
|
| Rate for Payer: BCN Commercial |
$15.11
|
| Rate for Payer: BCN Commercial |
$6.24
|
| Rate for Payer: BCN Commercial |
$16.42
|
| Rate for Payer: BCN Commercial |
$18.39
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$17.92
|
| Rate for Payer: Cash Price |
$14.72
|
| Rate for Payer: Cofinity Commercial |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$17.30
|
| Rate for Payer: Cofinity Commercial |
$7.14
|
| Rate for Payer: Cofinity Commercial |
$18.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.72
|
| Rate for Payer: Healthscope Commercial |
$21.73
|
| Rate for Payer: Healthscope Commercial |
$17.85
|
| Rate for Payer: Healthscope Commercial |
$19.40
|
| Rate for Payer: Healthscope Commercial |
$7.37
|
| Rate for Payer: Healthscope Whirlpool |
$22.40
|
| Rate for Payer: Healthscope Whirlpool |
$7.60
|
| Rate for Payer: Healthscope Whirlpool |
$18.40
|
| Rate for Payer: Healthscope Whirlpool |
$20.00
|
| Rate for Payer: Mclaren Commercial |
$16.56
|
| Rate for Payer: Mclaren Commercial |
$6.84
|
| Rate for Payer: Mclaren Commercial |
$18.00
|
| Rate for Payer: Mclaren Commercial |
$20.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.64
|
| Rate for Payer: Nomi Health Commercial |
$16.40
|
| Rate for Payer: Nomi Health Commercial |
$6.23
|
| Rate for Payer: Nomi Health Commercial |
$18.37
|
| Rate for Payer: Nomi Health Commercial |
$15.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.69
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$221.35
|
|
|
Service Code
|
NDC 904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.01 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Aetna Commercial |
$199.22
|
| Rate for Payer: ASR ASR |
$214.71
|
| Rate for Payer: BCBS Trust/PPO |
$181.77
|
| Rate for Payer: BCN Commercial |
$181.77
|
| Rate for Payer: Cash Price |
$177.08
|
| Rate for Payer: Cofinity Commercial |
$208.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.08
|
| Rate for Payer: Healthscope Commercial |
$214.71
|
| Rate for Payer: Healthscope Whirlpool |
$221.35
|
| Rate for Payer: Mclaren Commercial |
$199.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.15
|
| Rate for Payer: Nomi Health Commercial |
$181.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$194.79
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$221.35
|
|
|
Service Code
|
NDC 904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Aetna Commercial |
$199.22
|
| Rate for Payer: Aetna Medicare |
$81.90
|
| Rate for Payer: ASR ASR |
$214.71
|
| Rate for Payer: BCBS Complete |
$88.54
|
| Rate for Payer: BCBS Trust/PPO |
$182.50
|
| Rate for Payer: BCN Commercial |
$182.50
|
| Rate for Payer: Cash Price |
$177.08
|
| Rate for Payer: Cofinity Commercial |
$208.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.08
|
| Rate for Payer: Healthscope Commercial |
$214.71
|
| Rate for Payer: Healthscope Whirlpool |
$221.35
|
| Rate for Payer: Mclaren Commercial |
$199.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$177.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.15
|
| Rate for Payer: Nomi Health Commercial |
$181.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$193.95
|
| Rate for Payer: Priority Health Narrow Network |
$155.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$194.79
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$22.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Aetna Commercial |
$20.52
|
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Aetna Commercial |
$21.06
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: ASR ASR |
$22.12
|
| Rate for Payer: ASR ASR |
$22.70
|
| Rate for Payer: BCBS Trust/PPO |
$6.41
|
| Rate for Payer: BCBS Trust/PPO |
$18.72
|
| Rate for Payer: BCBS Trust/PPO |
$19.22
|
| Rate for Payer: BCN Commercial |
$19.22
|
| Rate for Payer: BCN Commercial |
$18.72
|
| Rate for Payer: BCN Commercial |
$6.41
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$18.24
|
| Rate for Payer: Cash Price |
$18.72
|
| Rate for Payer: Cofinity Commercial |
$21.43
|
| Rate for Payer: Cofinity Commercial |
$22.00
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.72
|
| Rate for Payer: Healthscope Commercial |
$22.70
|
| Rate for Payer: Healthscope Commercial |
$22.12
|
| Rate for Payer: Healthscope Commercial |
$7.57
|
| Rate for Payer: Healthscope Whirlpool |
$23.40
|
| Rate for Payer: Healthscope Whirlpool |
$7.80
|
| Rate for Payer: Healthscope Whirlpool |
$22.80
|
| Rate for Payer: Mclaren Commercial |
$21.06
|
| Rate for Payer: Mclaren Commercial |
$20.52
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.38
|
| Rate for Payer: Nomi Health Commercial |
$19.19
|
| Rate for Payer: Nomi Health Commercial |
$18.70
|
| Rate for Payer: Nomi Health Commercial |
$6.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.06
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$22.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$22.80 |
| Rate for Payer: Aetna Commercial |
$20.52
|
| Rate for Payer: Aetna Commercial |
$21.06
|
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: Aetna Medicare |
$8.44
|
| Rate for Payer: Aetna Medicare |
$2.89
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: ASR ASR |
$22.12
|
| Rate for Payer: ASR ASR |
$22.70
|
| Rate for Payer: BCBS Complete |
$9.12
|
| Rate for Payer: BCBS Complete |
$3.12
|
| Rate for Payer: BCBS Complete |
$9.36
|
| Rate for Payer: BCBS Trust/PPO |
$18.80
|
| Rate for Payer: BCBS Trust/PPO |
$19.29
|
| Rate for Payer: BCBS Trust/PPO |
$6.43
|
| Rate for Payer: BCN Commercial |
$18.80
|
| Rate for Payer: BCN Commercial |
$19.29
|
| Rate for Payer: BCN Commercial |
$6.43
|
| Rate for Payer: Cash Price |
$18.72
|
| Rate for Payer: Cash Price |
$18.24
|
| Rate for Payer: Cash Price |
$18.72
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$18.24
|
| Rate for Payer: Cofinity Commercial |
$22.00
|
| Rate for Payer: Cofinity Commercial |
$21.43
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.72
|
| Rate for Payer: Healthscope Commercial |
$7.57
|
| Rate for Payer: Healthscope Commercial |
$22.12
|
| Rate for Payer: Healthscope Commercial |
$22.70
|
| Rate for Payer: Healthscope Whirlpool |
$23.40
|
| Rate for Payer: Healthscope Whirlpool |
$22.80
|
| Rate for Payer: Healthscope Whirlpool |
$7.80
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Mclaren Commercial |
$21.06
|
| Rate for Payer: Mclaren Commercial |
$20.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.38
|
| Rate for Payer: Nomi Health Commercial |
$6.40
|
| Rate for Payer: Nomi Health Commercial |
$18.70
|
| Rate for Payer: Nomi Health Commercial |
$19.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.24
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: Priority Health Narrow Network |
$1.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.06
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$231.92
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$231.92 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: Aetna Medicare |
$69.56
|
| Rate for Payer: Aetna Medicare |
$85.81
|
| Rate for Payer: ASR ASR |
$224.96
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS Trust/PPO |
$191.22
|
| Rate for Payer: BCBS Trust/PPO |
$155.01
|
| Rate for Payer: BCN Commercial |
$155.01
|
| Rate for Payer: BCN Commercial |
$191.22
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Cofinity Commercial |
$218.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$224.96
|
| Rate for Payer: Healthscope Commercial |
$182.37
|
| Rate for Payer: Healthscope Whirlpool |
$231.92
|
| Rate for Payer: Healthscope Whirlpool |
$188.01
|
| Rate for Payer: Mclaren Commercial |
$208.73
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$185.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$150.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.13
|
| Rate for Payer: Nomi Health Commercial |
$154.17
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$6.21
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$6.21
|
| Rate for Payer: Priority Health Narrow Network |
$4.97
|
| Rate for Payer: Priority Health Narrow Network |
$4.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.09
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$188.01
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.01 |
| Max. Negotiated Rate |
$188.01 |
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: ASR ASR |
$224.96
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: BCBS Trust/PPO |
$190.45
|
| Rate for Payer: BCBS Trust/PPO |
$154.39
|
| Rate for Payer: BCN Commercial |
$190.45
|
| Rate for Payer: BCN Commercial |
$154.39
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Cofinity Commercial |
$218.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$182.37
|
| Rate for Payer: Healthscope Commercial |
$224.96
|
| Rate for Payer: Healthscope Whirlpool |
$231.92
|
| Rate for Payer: Healthscope Whirlpool |
$188.01
|
| Rate for Payer: Mclaren Commercial |
$208.73
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| Rate for Payer: Nomi Health Commercial |
$154.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.09
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$263.04
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.28 |
| Max. Negotiated Rate |
$263.04 |
| Rate for Payer: Aetna Commercial |
$236.74
|
| Rate for Payer: ASR ASR |
$255.15
|
| Rate for Payer: BCBS Trust/PPO |
$216.01
|
| Rate for Payer: BCN Commercial |
$216.01
|
| Rate for Payer: Cash Price |
$210.43
|
| Rate for Payer: Cofinity Commercial |
$247.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.43
|
| Rate for Payer: Healthscope Commercial |
$255.15
|
| Rate for Payer: Healthscope Whirlpool |
$263.04
|
| Rate for Payer: Mclaren Commercial |
$236.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.58
|
| Rate for Payer: Nomi Health Commercial |
$215.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$197.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.48
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$813.60
|
|
|
Service Code
|
NDC 74662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.03 |
| Max. Negotiated Rate |
$813.60 |
| Rate for Payer: Aetna Commercial |
$732.24
|
| Rate for Payer: Aetna Medicare |
$301.03
|
| Rate for Payer: ASR ASR |
$789.19
|
| Rate for Payer: BCBS Complete |
$325.44
|
| Rate for Payer: BCBS Trust/PPO |
$670.81
|
| Rate for Payer: BCN Commercial |
$670.81
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Commercial |
$764.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Healthscope Commercial |
$789.19
|
| Rate for Payer: Healthscope Whirlpool |
$813.60
|
| Rate for Payer: Mclaren Commercial |
$732.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$650.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Nomi Health Commercial |
$667.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$712.88
|
| Rate for Payer: Priority Health Narrow Network |
$570.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$715.97
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$263.04
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.32 |
| Max. Negotiated Rate |
$263.04 |
| Rate for Payer: Aetna Commercial |
$236.74
|
| Rate for Payer: Aetna Medicare |
$97.32
|
| Rate for Payer: ASR ASR |
$255.15
|
| Rate for Payer: BCBS Complete |
$105.22
|
| Rate for Payer: BCBS Trust/PPO |
$216.88
|
| Rate for Payer: BCN Commercial |
$216.88
|
| Rate for Payer: Cash Price |
$210.43
|
| Rate for Payer: Cofinity Commercial |
$247.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.43
|
| Rate for Payer: Healthscope Commercial |
$255.15
|
| Rate for Payer: Healthscope Whirlpool |
$263.04
|
| Rate for Payer: Mclaren Commercial |
$236.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$210.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.58
|
| Rate for Payer: Nomi Health Commercial |
$215.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$197.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$230.48
|
| Rate for Payer: Priority Health Narrow Network |
$184.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.48
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.63
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna Commercial |
$2.37
|
| Rate for Payer: Aetna Medicare |
$0.97
|
| Rate for Payer: ASR ASR |
$2.55
|
| Rate for Payer: BCBS Complete |
$1.05
|
| Rate for Payer: BCBS Trust/PPO |
$2.17
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.55
|
| Rate for Payer: Healthscope Whirlpool |
$2.63
|
| Rate for Payer: Mclaren Commercial |
$2.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Nomi Health Commercial |
$2.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.97
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.31
|
| Rate for Payer: Priority Health Narrow Network |
$1.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.32
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$416.10
|
|
|
Service Code
|
NDC 904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$312.07 |
| Max. Negotiated Rate |
$416.10 |
| Rate for Payer: Aetna Commercial |
$374.49
|
| Rate for Payer: ASR ASR |
$403.62
|
| Rate for Payer: BCBS Trust/PPO |
$341.70
|
| Rate for Payer: BCN Commercial |
$341.70
|
| Rate for Payer: Cash Price |
$332.88
|
| Rate for Payer: Cofinity Commercial |
$391.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.88
|
| Rate for Payer: Healthscope Commercial |
$403.62
|
| Rate for Payer: Healthscope Whirlpool |
$416.10
|
| Rate for Payer: Mclaren Commercial |
$374.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.69
|
| Rate for Payer: Nomi Health Commercial |
$341.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$366.17
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna Commercial |
$2.37
|
| Rate for Payer: ASR ASR |
$2.55
|
| Rate for Payer: BCBS Trust/PPO |
$2.16
|
| Rate for Payer: BCN Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.55
|
| Rate for Payer: Healthscope Whirlpool |
$2.63
|
| Rate for Payer: Mclaren Commercial |
$2.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Nomi Health Commercial |
$2.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.32
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.96 |
| Max. Negotiated Rate |
$337.73 |
| Rate for Payer: Aetna Commercial |
$303.95
|
| Rate for Payer: Aetna Medicare |
$124.96
|
| Rate for Payer: ASR ASR |
$327.59
|
| Rate for Payer: BCBS Complete |
$135.09
|
| Rate for Payer: BCBS Trust/PPO |
$278.45
|
| Rate for Payer: BCN Commercial |
$278.45
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$317.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$327.59
|
| Rate for Payer: Healthscope Whirlpool |
$337.73
|
| Rate for Payer: Mclaren Commercial |
$303.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$270.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$295.91
|
| Rate for Payer: Priority Health Narrow Network |
$236.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$297.20
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$813.60
|
|
|
Service Code
|
NDC 74662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$610.20 |
| Max. Negotiated Rate |
$813.60 |
| Rate for Payer: Aetna Commercial |
$732.24
|
| Rate for Payer: ASR ASR |
$789.19
|
| Rate for Payer: BCBS Trust/PPO |
$668.13
|
| Rate for Payer: BCN Commercial |
$668.13
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Commercial |
$764.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Healthscope Commercial |
$789.19
|
| Rate for Payer: Healthscope Whirlpool |
$813.60
|
| Rate for Payer: Mclaren Commercial |
$732.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Nomi Health Commercial |
$667.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$715.97
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$416.10
|
|
|
Service Code
|
NDC 904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.96 |
| Max. Negotiated Rate |
$416.10 |
| Rate for Payer: Aetna Commercial |
$374.49
|
| Rate for Payer: Aetna Medicare |
$153.96
|
| Rate for Payer: ASR ASR |
$403.62
|
| Rate for Payer: BCBS Complete |
$166.44
|
| Rate for Payer: BCBS Trust/PPO |
$343.07
|
| Rate for Payer: BCN Commercial |
$343.07
|
| Rate for Payer: Cash Price |
$332.88
|
| Rate for Payer: Cofinity Commercial |
$391.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.88
|
| Rate for Payer: Healthscope Commercial |
$403.62
|
| Rate for Payer: Healthscope Whirlpool |
$416.10
|
| Rate for Payer: Mclaren Commercial |
$374.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$332.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.69
|
| Rate for Payer: Nomi Health Commercial |
$341.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$364.59
|
| Rate for Payer: Priority Health Narrow Network |
$291.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$366.17
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.73
|
|
|
Service Code
|
NDC 378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.29 |
| Max. Negotiated Rate |
$337.73 |
| Rate for Payer: Aetna Commercial |
$303.95
|
| Rate for Payer: ASR ASR |
$327.59
|
| Rate for Payer: BCBS Trust/PPO |
$277.34
|
| Rate for Payer: BCN Commercial |
$277.34
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$317.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$327.59
|
| Rate for Payer: Healthscope Whirlpool |
$337.73
|
| Rate for Payer: Mclaren Commercial |
$303.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$297.20
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$8,140.80
|
|
|
Service Code
|
NDC 74714819
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,012.10 |
| Max. Negotiated Rate |
$8,140.80 |
| Rate for Payer: Aetna Commercial |
$7,326.72
|
| Rate for Payer: Aetna Medicare |
$3,012.10
|
| Rate for Payer: ASR ASR |
$7,896.58
|
| Rate for Payer: BCBS Complete |
$3,256.32
|
| Rate for Payer: BCBS Trust/PPO |
$6,712.09
|
| Rate for Payer: BCN Commercial |
$6,712.09
|
| Rate for Payer: Cash Price |
$6,512.64
|
| Rate for Payer: Cofinity Commercial |
$7,652.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,512.64
|
| Rate for Payer: Healthscope Commercial |
$7,896.58
|
| Rate for Payer: Healthscope Whirlpool |
$8,140.80
|
| Rate for Payer: Mclaren Commercial |
$7,326.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,512.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,919.68
|
| Rate for Payer: Nomi Health Commercial |
$6,675.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,105.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$7,132.97
|
| Rate for Payer: Priority Health Narrow Network |
$5,706.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7,163.90
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$8,140.80
|
|
|
Service Code
|
NDC 74714819
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,105.60 |
| Max. Negotiated Rate |
$8,140.80 |
| Rate for Payer: Aetna Commercial |
$7,326.72
|
| Rate for Payer: ASR ASR |
$7,896.58
|
| Rate for Payer: BCBS Trust/PPO |
$6,685.22
|
| Rate for Payer: BCN Commercial |
$6,685.22
|
| Rate for Payer: Cash Price |
$6,512.64
|
| Rate for Payer: Cofinity Commercial |
$7,652.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,512.64
|
| Rate for Payer: Healthscope Commercial |
$7,896.58
|
| Rate for Payer: Healthscope Whirlpool |
$8,140.80
|
| Rate for Payer: Mclaren Commercial |
$7,326.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,919.68
|
| Rate for Payer: Nomi Health Commercial |
$6,675.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,105.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7,163.90
|
|
